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Underground StoraPT7ank Program g m arm Tank I�rmation Form <br /> FACILITY1taTE INFORMATION(Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME <br /> o ,pb CONTACT NAKE <br /> C ADDRESS(Street address of TANK location) <br /> I PHONE# (with area code) <br /> L <br /> I CITY STATE ZIP CODE NEAR EST CROSS STREET <br /> T Y t'rr4- <br /> Y CHECK HERE if this ADDRESS should be used for Legal Not ifi tion <br /> i <br /> OPERATOR INFORMATION&ADDRESS (Complete If information different from above.) <br /> 0 NAME <br /> OPERATOR CONTACT NAME <br /> P <br /> E MAILING or STREET ADDRESS <br /> R OPERATOR PI IONE# (with area code) <br /> T CITY STATE iGIP CODE <br /> 0 <br /> It CHECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete irdifferent from above.) <br /> NAME <br /> OWNER CON"T'ACf NAME <br /> O <br /> W MAILING or STREET ADDRESS <br /> N OWNER PHONE#(with area code) <br /> E <br /> R CITY STATE IIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notificat' <br /> CHECK APPROPRIATE BOX <br /> T ACTIVE FARM TANK SITE <br /> Y (One or more underground TANKS > 1.100 gallon capacity) <br /> P EXEMPT FARM TANK SITE (ALL undci ground TANKS at site = to or < 1,100 gallon capacity) <br /> E PERMANENTLY CLOSED FARM TANK SITE <br /> (ALL undes ground TANKS at sitemoved r closed in place) <br /> UNDERGROUND TANK INFORMATION(List additional tank Information on separate shert If needed.) <br /> T TAW Saa CIMMICALS STORED ESTIMATED DATE LAST Usui Melt:OD OF CLOSURE DATP OFAova tt <br /> A (aAL LONS) CURRENMY OR PREVIOUSLY IF CURREWLY I3MPTY <br /> N 1F PERhIAI+tCN'1LY CLQSCD CLDSUftf:W i'I-ACC <br /> Kx� <br /> N <br /> F <br /> 0 <br /> TIRS FOItM}Itis S CO UNDER PENALTY OF PENURY,AND TO711H BEST OF MY KNOWLEI►GK IS TRUE ANL CORRECT. <br /> NAME <br /> TITLE 4 aG,� <br /> OFFICE USE O Y DATr <br /> SWEM 0 COMP 0 LrOCCODE DIST OD) "VEUG" i <br /> LXr'-NWT UGT if CL WED UG'I' EEPS PIt(jM,.Uli an)u DATE: <br /> EH 23 044(1288) f ` <br />